English | Español
Skip Navigation LinksHome / Brokers / Medical Policies

Medical Policies

If you are an Arkansas State or Public School employee, please click here for your medical policies.

High Tech Imaging (MRI, CT, PET) and Nuclear Medicine    Administered by Care Core National

Click here to view


Effective Date: 04/14/2005 Title: Cartilage Transplants of Lower Extremity
Revision Date: 12/10/2008 Document: BI101:00
CPT Code(s): 27415, 27416, 29866-29868

Cartilage transplants in the lower extremity include transplants of various portions of the knee or ankle. While allograft application in this area is new and mostly in experimental or investigational mode, some few procedures may be authorized under special circumstances. These procedures require pre-authorization.

1)    QualChoice considers allograft transplant of the knee (anterior cruciate ligament, osteochondral, and meniscus) medically necessary when selection criteria are met.

a)    Anterior Cruciate Ligament (ACL):

i)      Members with ACL deficiency who are not candidates for autogenous transplantation (e.g., individuals whose autogenous tissues have been compromised by previous surgery, previous injury), or

ii)     Members with pathology such as chronic patellar tendonitis, and hamstring injury, or

iii)    Members with any other contra-indications to using their own tissue such as collagen disease or generalized ligamentous laxity.

b)    Osteochondral:

i)      Treatment of an isolated, traumatic injury that is full-thickness depth (grade 4, down to and/or including the bone) lesion, preferably surrounded by normal, healthy (non-arthritic) cartilage. The opposing articular surface should be generally free of disease or injury; or

ii)     Non-repairable stage 3 or 4 osteochondritis dissecans; or

iii)    Avascular necrosis lesions of the femoral condyle; or

iv)   Otherwise healthy, active members who have either failed earlier arthroscopic procedures or are not candidates for such procedures because of the size, shape, or location of the lesion.

c)    Meniscus:

i)      Members under the age of 45, and

ii)     Pre-operative studies (MRI or previous arthroscopy) reveal absence or near-absence of the meniscus, and

iii)    Degenerative changes must be absent or minimal, and

iv)   Knee must be stable (i.e., intact or reconstructed ACL).

2)    QualChoice considers osteochondral allograft of talus experimental and investigational because there are unanswered questions regarding the clinical outcomes of this approach when compared with ankle arthrodesis, especially in terms of pain, disability, function, and durability.

3)    QualChoice considers autologous osteochondral mosaicplasty experimental and investigational because its effectiveness in the treatment of articular cartilage defects/lesions has not been established.

4)    QualChoice considers osteochondral autograft transfer system (OATS) experimental and investigational because its effectiveness in the treatment of articular cartilage defects/lesions has not been established.

Codes Used In This BI:

27415      Ostrochondral Allograft, knee, open;

27416      Ostrochondral Autograft, knee, open; (eg, mosaicplasty)

29866      Arthroscopy, Knee, Surgical; osteochondral autograft(s)

29867      Arthroscopy, knee, surgical; osteochondral allograft;

29868      Arthroscopy, knee, surgical; meniscal transplantation, medial or lateral

  1. Bakay A, Csonge L, Papp G, et al. Osteochondral resurfacing of the knee joint with allograft. Clinical analysis of 33 cases. Int Orthop. 1998;22(5):277-281.
  2. Chu CR, Convery FR, Akeson WH, et al. Articular cartilage transplantation. Clinical results in the knee. Clin Orthop. 1999;360:159-168.
  3. Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up. Arthroscopy. 2001;17(1):9-13.
  4. Allum RL. BASK Instructional Lecture 1: Graft selection in anterior cruciate ligament reconstruction. Knee. 2001;8(1):69-72.
  5. Felix NA, Paulos LE. Current status of meniscal transplantation. Knee. 2003;10(1):13-17.
  6. Washington State Department of Labor and Industries, Office of the Medical Director. Meniscal allograft. Health Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries; revised October 22, 2002. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/AciUpdate.pdf.
  7. Gross AE, Agnidis Z, Hutchison CR. Osteochondral defects of the talus treated with fresh osteochondral allograft transplantation. Foot Ankle Int. 2001;22(5):385-391.
  8. Hayes DW Jr, Averett RK. Articular cartilage transplantation. Current and future limitations and solutions. Clin Podiatr Med Surg. 2001;18(1):161-176.
  9. Tasto JP, Ostrander R, Bugbee W, Brage M. The diagnosis and management of osteochondral lesions of the talus: Osteochondral allograft update. Arthroscopy. 2003;19 Suppl 1:138-141.
New Page 2

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
Dental and Vision
  • MediQ65 Sup
  • GetSmart
  • Text4Baby
  • URAC In-Process Seal
< >
Copyright © 2014 QualChoice®. All Rights Reserved. Web Design & Web Development by Aristotle®.